Legacy Health And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure residents at risk for falls were supervised and fall prevention interventions were implemented for 1 (Resident #36) of 1 sampled residents, to prevent falls and possible serious injury; failed to ensure 3 of 3 clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services for 1 of 1 laundry room; and failed to ensure the safety of a resident by transferring 2 (Residents #87 and #304 ) sampled residents without a gait belt. The findings are: 1. A review of a Face Sheet indicated Resident #36 had a diagnosis of Dementia. a. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2024 revealed Resident #36 had a Staff Assessment for Mental Status (SAMS) score of 1, which indicated a memory problem. b. Resident #36's Care Plan with a review date 02/09/2023 revealed the resident had a potential for falls. Interventions included: encourage clutter free environment and path to bathroom, initiated 12/17/2022; encourage use of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a securement device was used for residents with urinary inswelling catheters in place for 1 (Resident #68) of 5 sampled residents who had a catheter The findings are: 1. Resident (R) #68 had a diagnosis of Neuromuscular dysfunction of bladder, unspecified. The Minimum Data Set with an Assessment Reference Date of 01/01/2024 documented a Brief Interview for Mental Status score of 14 (13-15 indicates cognitively intact). 2. A Physician ' s Order with an Order Date of 01/25/2024 documented, (Indwelling) catheter may use leg band . 3. On 03/18/2024 at 02:11 PM, the Surveyor observed that R #68 did not have any securement device to hold their indwelling catheter tubing in place to prevent tubing from being pulled and causing trauma. 4. On 03/19/2024 at 09:40 AM, the Surveyor observed that R #68 did not have a securement device to hold their inswelling catheter tubing in place. 5. On 03/21/2024 at 08:32 AM, the Surveyor asked Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, and record review, the facility failed to (1) ensure medications were readily available at all times for 1 (Resident #28) of 1 sampled resident, who was on scheduled pain medication, to prevent possible increase in pain or further decline in status, (2) ensure that staff performed hand hygiene while providing incontinence care for 1 (Resident #32) sampled resident, (3) ensure that staff utilized adjustable chairs in a manner that avoided causing a restraint for 1 (Resident #36) sampled resident, (4) ensure that privacy was maintained while providing bathing and incontinence care for 3 (Residents #61, #72, and #304) sampled residents, and (5) ensure that safety devices were utilized while lifting and transferring for 2 (Residents #87 and #304) sampled residents. The findings are: Resident #28 had diagnoses of Chronic pain and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2024 documented a Brief Interview for Mental Status (BIMS) score of 10 (8-12 indicates moderate cognitive impairment). Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were readily available at all times for 1 (Resident #28) of 1 sampled resident, who was on scheduled pain medication, to prevent possible increase in pain or further decline in status. The findings are: A Face Sheet indicated the facility admitted Resident #28 with diagnoses of Chronic pain and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2024 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. A review of Resident #28's Physician Orders, for the month of 03/2024, revealed an order, dated 02/02/2024, for Lyrica (a medication given for pain) 150 milligram (mg), one capsule twice daily for pain. Review of Resident 28's Care Plan, initiated 09/27/2022, revealed the resident will not have unrelieved pain times (x) 90 days as evidenced by (AEB) no moaning, groaning, or facial grimaces. Interventions included coordinate with physician to manage pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff washed and/or sanitized their hands during meal service in the facility's dining room to prevent cross-contamination which had the potential to affect the 23 residents residing in the dining area, that the laundry workers handled resident garments in a manner that avoided contamination, and that The findings are: 1. On 03/18/2024 at 12:19 PM, the Surveyor observed a Registered nurse (RN) get a soft drink out of the vending machine for a resident. The RN then picked up a tray to deliver to a resident at a table, then while going back to get another tray placed his/her hands in their pocket. The RN then touched his/her face before picking up another tray to deliver to a resident without sanitizing their hands. a. On 03/18/2024 at 12:32 PM, the Surveyor observed a Certified Nursing Assistant (CNA) pick up a chair, move it over to the table, move their hair away from their face, and begin feeding a resident without sanitizing hands. b. On 03/18/2024 at 12:32 PM, the Surveyor observed a CNA sit down…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY According to record review, observations, and interview the facility failed to ensure that a clean, safe, comfortable homelike environment was provided in rooms [ROOM NUMBER], the Resident Bathroom in the secure unit, the Dayroom/Dining Room in the secure unit, and for 1 (Resident #50) sampled resident. The findings are: On 03/20/2024 at 04:05 PM, the Surveyor did environmental rounds with Maintenance. These are the findings: In room [ROOM NUMBER] the Surveyor observed on several ceiling tiles brown areas that were round with irregular borders. On Side B where the bed was against the wall there were varying vertical stripes of stripped paint exposing cinder block. The damage ran the length of the bed. When Maintenance saw the area, he/she said that it was a rather large area that has not been reported. In room [ROOM NUMBER] the Surveyor observed on Side A in between the bed and nightstand a horizontal rectangular area that is missing paint and two nails are exposed from chipped drywall. The area has chipped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure Dementia in-service training was provided in the past year. The findings are: 1. On 03/21/2024 at 8:20 AM, the Surveyor reviewed in-services and competency training for the past year and did not locate a Dementia in-service. The Surveyor requested the Dementia In-Service. 2. On 03/21/2024 at 9:00 AM, the LPN #2 stated We looked through all the in-services and could not find one for Dementia. 3. On 03/31/2024 at 9:00 AM, LPN #2 indicated that she had just taken this position over and was trying to get everything in order but was unsure if staff had dementia training prior to her taking this position. .

Based on observation, interview, and record review, the facility failed to ensure a resident individualized care plan was updated to ensure appropriate care was received for 1 (Resident #78) of 1 sampled resident who had no order for any type of nail care to be provided, and no care plan interventions regarding a device related to contracture. This failed practice had the potential to affect 94 residents The findings are: 1. On 03/18/2024 at 11:31 AM, the Surveyor observed Resident (R) #78 had fingernails 1/3 to 1/2 inch long with a brown substance underneath them. a. On 03/19/2024 at 09:34 AM, the Surveyor observed R #78 had fingernails 1/3 to 1/2 inch long with a brown substance underneath them. b. On 03/20/2024 at 02:57 PM, the care plan for R #78 did not document a need for nail care. c. On 03/20/2024 at 04:19 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, Who is responsible for trimming a resident's fingernails? CNA #6 stated, The CNAs are unless they are diabetic, then the nurses do. The Surveyor asked, How often do the residents get their nails trimmed? CNA #6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services were provided to minimize the potential for further decline in range of motion for 1 (Resident #78) of 11 residents who had contractures with limited range of motion. The findings are: 1. On 03/18/2024 at 11:31 am, the Surveyor observed Resident (R) #78 ' s left hand with fingers bent underneath. The Surveyor asked R #78 if he/she could stretch their fingers out, and R#78 stated, I can't anymore. The Surveyor asked the resident, Do you have a splint for your hand? R #78 stated, No I don't. The Surveyor asked, Do staff place a carrot (a device used to prevent the fingers from pressing into the palm) or a roll in your hand? R #78 stated, No ma'am. 2. On 03/19/2024 at 09:34 am, the Surveyor observed R #78 with their left hand resting on their stomach and fingers bent underneath. No type of device present in hand. 3. On 03/21/2024 at 10:52 am, Certified Nursing Assistant (CNA) #9 was asked, What should a resident have in place…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

According to observation, interview, and record review, the facility failed to ensure the dignity of 3 (Resident #61, #72, and #304) sampled residents by not pulling the curtain or closing the door, leaving them exposed for any visitors to see from the hallway. The findings are: 1. Resident #72 had diagnoses of Parkinson's without fluctuations and Dementia without behavioral disturbances. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2024 revealed the resident received a score of 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), and that the resident is dependent for transfers. A. On 03/19/2024 at 08:52 AM, the Surveyor observed the shower room door open with Resident #72 sitting fully naked in a shower chair, curtain and door not pulled. Resident #72 was fully visible from the hallway. B. On 03/20/2024 at 09:30 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4, When transferring Resident #72 yesterday to the shower, should the curtain have been pulled and the door closed? CNA #4 said, Yes it should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure food items stored in the freezer were covered, sealed, and dated; kitchen vents were cleaned to provide a sanitary environment for food preparation; floors, dish washer, kitchen walls, door frames and baseboards were free of rotten wood; chipped floor tiles were free of debris, dirt, grease, grime, rust, stains, and spills; ceiling tiles were replaced and in a sanitary condition; and dietary staff washed their hands before they handled clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 89 residents who received meals from the kitchen (total census: 95), as documented on a list provided by the Dietary Supervisor on 12/29/22 at 3:22 PM The findings are: 1. On 12/27/22 at 10:25 AM, an opened box of cod was stored in the freezer. The box was not covered or sealed. 2. On 12/27/22 at 10:28 AM, the floor to the deep fryer cabinet and the 4 pallets had accumulation of grease build up on them. The Surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure staff did not stand over residents while they assisted with meals and failed to ensure staff did not allow a resident to eat food that had been touched by another resident which failed to promote resident's dignity for 1 (Resident #69) of 3 (Resident #33, #69, #85) sampled residents who required assistance with meals and received their meal trays in the unit dining room. This failed practice had the potential to affect 19 residents who required assistance with eating as documented on a list provided by the Director of Nursing (DON). The findings are: 1. Resident #69 had diagnoses of Hypertension and Chronic Kidney disease. The Quarterly Minimum Data Set with an Assessment Reference Date of 1/1/2022 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview Mental Status (BIMS) and required limited assistance of one person assistance with eating. a. The Care Plan dated 5/28/2020 documented, .Provide visual encouragement. b. On 12/27/22 at 12:39 PM, Resident #69…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment was provided for residents living on the North Hall secure unit. The findings are: 1. On 12/27/22 at 10:40 AM, the covering of the middle arm rest and dual cup holder of a brown couch in the secure unit day room was torn. [NAME] and internal insulation of the couch were visible. The wood in the area for the two cup holders had jagged non-smooth edges. 2. On 12/28/22 at 8:02 AM, the brown couch in the secure unit day room had an additional tear in the covering on the front side of the couch. 3. On 12/28/22 at 5:12 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4, How long has the couch been in that condition? CNA #4 stated, At least a couple of months. They've known about it and haven't done anything because these folks are rough on stuff. The Surveyor asked, has it been reported to Maintenance? CNA #4 stated, I'm sure he knows because staff see it every day. 4. On 12/29/22 at 9:11 AM, the Surveyor accompanied the Maintenance Supervisor (MS) to the North Hall secure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assistance with Activities of Daily Living (ADL) was provided to 1 (Resident #9) of 13 (Residents #2, R #7, R #9, R #44, R #59, R #60, R #61, R #74, R #79, R #80, R #81, R #85, and R #248) sample residents who were dependent on staff for ADL care per the ADL Care List provided by the Director of Nursing (DON) on 12/29/22. The findings are: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses of Rheumatoid arthritis, Disorders of the skin, and Allergic Rhinitis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/22 documented the Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) and required full staff performance, total dependance, for Bed mobility, Transfer, Toilet use, Bathing, and one-person physical assistance for eating. a. On 12/27/22 at 11:44 AM, during initial rounds, R #9 informed the Surveyor, I'm not getting lotion on my hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure oxygen was administered at the physician ordered flow rate for 1 (Resident #248) and Physician Orders were documented for 1 (Resident #80) of 9 (Resident #24, R #54, R #57, R #63, R #72, R #74, R #79, R #247, R #248) sample residents who received oxygen. This failed practice had the potential to affect 22 residents according to the Oxygen list provided by the Director of Nursing (DON) on 12/29/22 at 5:05 pm. The findings are: 1. Resident #80 was readmitted on [DATE] from a hospital stay. A Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/22 documented a 15 (13-15 indicated cognitively intact) on a Brief Interview for Mental Status (BIMS), Section O had no documentation of oxygen use. Resident #80 was not documented on the list of residents receiving Oxygen Therapy provided by the DON on 12/29/22 at 5:05 PM. a. On 12/27/22 at 12:05 PM, Resident #80 was in his room with oxygen via nasal cannula…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure pain management consistent with professional standards of practice was provided to meet the needs of 1 (Resident #9) of 6 (Resident #9, #24, #57, #61, #63 and #81) sample residents reviewed who had Physician Orders for regularly scheduled pain medication. This failed practice had the potential to affect 21 residents according to a list provided by the Director of Nursing (DON) on 12/29/22 at 5:05 PM. The findings are: 1. Resident #9 was admitted to facility on 06/15/11 with Diagnoses of Rheumatoid Arthritis and Cerebrovascular Accident. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/22 documented the resident scored a 15 (13-15 Indicates Cognitively Intact) on a Brief Interview for Mental Status (BIMS), Section J documented, .been on scheduled pain regimen and received PRN [as needed] pain medication . Pain interview questions were blank. a. On 12/27/22 at 11:44 AM, Resident #9 said to the Surveyor. The nurse told me this morning that I was out of my pain pills. I'm hurting. They…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure Pharmacy Services were provided to meet the needs of 1 (Resident #9) of 6 (Resident #9, #24, #57, #61, #63 and #81) sample residents reviewed who had Physician Orders for regularly scheduled pain medication. This failed practice had the potential to affect 21 residents according to a list provided by the Director of Nursing (DON) on 12/29/22 at 5:05 PM. The findings are: 1. Resident #9 was admitted to facility on 06/15/11 with Diagnoses of Rheumatoid Arthritis and Cerebrovascular Accident. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/22 documented the resident scored a 15 (13-15 Indicates Cognitively Intact) on a Brief Interview for Mental Status (BIMS), Section J documented .been on scheduled pain regimen and received PRN [As needed] pain medication . Pain interview questions were blank. a. On 12/27/22 at 11:44 AM, Resident #9 said to the Surveyor. The nurse told me this morning that I was out of my pain pills. I'm hurting. They said they didn't know when they would get them…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure food was prepared by methods that maintained nutritive value, the appearance and encourage good nutritional intake for the residents who received pureed diets from 1 of 1 kitchen residents for 1 of 2 meals observed The failed practice had the potential to affect 6 residents who required pureed diets, 63 residents who received regular diet and 21 residents who received mechanical soft diets according to lists provided by the Dietary Supervisor on 12/29/2022. At 3:22 PM. The findings are: 1. On 12/27/22 at 9:56 AM, a pan of regular scalloped potatoes, a pan of turnip greens, a pan of ham slices, a pan of pureed ham, a pan of ground ham, a pan of pureed turnip greens, a pan of pureed scalloped potatoes, and a pan of pureed spaghetti were in the oven baking at the temperature of 350 degrees Fahrenheit. The Surveyor asked Dietary Employee # when did you she cook the lunch meal? She stated, I cooked at 9:00 AM and placed them in the oven at 9:30 AM. The Surveyor asked, at what temperature did you set the oven? She stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets, as documented on a list provided by the Dietary Supervisor on 12/28/2022. The findings are: 1. On 12/28/2022 at 11:52 AM, the following were on the steam table: a. A pan of pureed ham, the consistency of the pureed ham was more of mechanical soft and was not smooth. b. A pureed container of mixed vegetables, the consistency of the pureed mixed vegetables was lumpy and not smooth. There were pieces of carrots visible in the mixture. 2. On 2/27/22 at 1:46 PM, Dietary Employee (DE) #3 used #6 scoop and placed 8 servings of rice with chicken into a blender, added broth and pureed. At 1:52 PM, Dietary Employee #3 poured the pureed rice with chicken into a pan, covered the pan with foil, and placed it in the oven. The consistency of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents and immunization records were tracked timely for 3 (Resident #44, R #78, and R #81) of 5 (Resident #44, R #57, R #60, R #78 and R #81) sample selected residents who had signed consents for the pneumococcal vaccine to help protect against pneumococcal bacteria which can cause serious infections and is potentially fatal. The findings are: 1. On 12/29/22 at 11:38 AM, the Director of Nursing (DON) provided the Surveyor with a Pneumococcal Vaccination Status List. 2. On 12/30/22 at 08:05 AM, the Surveyor requested Pneumonia consents and declinations for R #44, R #57, R # 60, R #78, and R #81 from the Administrator. 3. On 12/30/22 at 12:55 PM, the Assistant Director of Nursing (ADON) provided the declinations and consents. The ADON stated, there were three consents who had not received vaccinations yet and those are on me. I have not done them yet. The Surveyor reviewed the Pneumococcal consents and found the following: a. Resident #44 had diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure the call light was placed within reach to meet the needs of 1 (Resident #248) of 17 (Residents #7, R #15, R# 21, R #24, R #54, R #55, R #57, R #63, R #67, R #72, R #74, R #79, R #80, R #85, #247, R #248, R #249) sample residents reviewed. This failed practice had the potential to affect 71 residents according to a list provided by the Director of Nursing (DON) on 12/29/22 at 5:05 pm. The findings are: 1. Resident #248 was admitted to the facility on [DATE] with Diagnoses of Acute Respiratory Failure with hypoxia, Hypertensive Heart Disease with Heart Failure, Acute on Chronic Diastolic Congestive Heart Failure, and Pneumonia due to other gram-negative bacteria. An admission Minimum Data Set (MDS) was in progress. a. On 12/27/22 at 11:08 am, Resident #248 was in room, the call light was hanging from the wall at the end of the bed. It was not in reach of the resident. b. On 12/27/22 at 11:30 am, the Surveyor asked Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Care Plan interventions were implemented and followed to maintain nutritional status and help prevent significant weight loss and failed to ensure the responsible party was notified of weight loss for 1 (Resident #55) of 4 (Resident #54, R #55, R #63, and R #79) sample residents with excessive weight loss per the Resident Matrix provided by the Director of Nursing (DON) 12/27/22 and corrected on 12/30/22. The findings are: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses of Alzheimer's, Dementia, Bipolar disorder, and Cognitive communication deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/22 documented the Brief Interview for Mental Status (BIMS) score of 0 (0-7 severely cognitively impaired) and required supervision, oversight, encouragement, or cueing for eating. a. On 12/27/22 at 12:28 PM, Certified Nursing Assistant (CNA) #2 delivered the lunch tray to R #55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure medications were consumed and not left unattended for 1 (Resident #248) sample residents. This failed practice had the potential to affect 95 residents according to a resident census list provided by the Director of Nursing (DON) on 12/27/22 at 10:14 AM. The findings are: 1. Resident #248 was admitted to the facility on [DATE] with Diagnoses of Acute Respiratory Failure with hypoxia, Hypertensive Heart Disease with Heart Failure, Acute on Chronic Diastolic Congestive Heart Failure, and Pneumonia due to other gram-negative bacteria. An admission Minimum Data Set (MDS) was in progress. a. On 12/27/22 at 11:30 AM, the Surveyor observed a cup of medication with five pills in it on the resident's bedside table. It was left unattended by a nurse. The call light was activated after being located at the end of the bed hanging from the wall. b. On 12/27 at 11:38 AM, Certified Nursing Assistant (CNA) #7 responded to the call light. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. The failed practices had the potential to affect 63 residents who received regular diets from the kitchen (total census: 95), according to a list provided by the Dietary Supervisor on 12/29/2022. The findings are: a. On 12/27/2022 at 3:22 PM, the menu for lunch documented the residents on regular diets received 3 ounces [oz] of glazed ham. b. On 12/27/2022 at 12:09 PM, Dietary Employee #1 served a small, dried piece of ham to the residents on regular diets. c. On 12/27/2022 at 1:23 PM, The Surveyor asked the Dietary Supervisor to weigh the same amount of meat served to the residents. The slice of ham weighed 1.5 ounce, instead of 3 ounces as specified on the menu.